OWHA Health Screening Questionnaire U18 (North Simcoe Girls Hockey Association)

Print OWHA Health Screening Questionnaire U18

This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice activity. This questionnaire may be completed verbally.

Questions

The answer to all questions must be “No” in order to participate in each on-ice activity. 1. Are you experiencing any of these symptoms?

Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher)^*
NoYes
Chills^*
NoYes
Cough that’s new or worsening (continuous, more than usual)^*
NoYes
Barking cough, making a whistling noise when breathing (croup)^*
NoYes
Shortness of breath (out of breath, unable to breathe deeply)^*
NoYes
Sore throat^*
NoYes
Difficulty swallowing^*
NoYes
Runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)^*
NoYes
Lost sense of taste or smell^*
NoYes
Pink eye (conjunctivitis)^*
NoYes
Headache that’s unusual or long lasting^*
NoYes
Digestive issues (nausea/vomiting, diarrhea, stomach pain)^*
NoYes
Muscle aches^*
NoYes
Extreme tiredness that is unusual (fatigue, lack of energy)^*
NoYes
Falling down often^*
NoYes
For young children and infants: sluggishness or lack of appetite^*
NoYes

Remaining questions

For the remaining questions, close physical contact means: Being less than 2 meters away in the same room, workspace, or area for over 15 minutes or living in the same home.

In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?^*
NoYes
In the last 14 days, have you been in close physical contact with a person who either: Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside of Canada in the last 2 weeks?^*
NoYes
Have you travelled outside of Canada in the last 14 days?^*
NoYes
Your name^*